Abstract
legislative rules on training, qualifications and duties of the nursing profession was the oldest and articulated in the history of health legislation. The operating limitations, duties, powers and framework of the legal profession has seen a profound evolution in time.
Seizing the specifications given by the World Health Organization, the Italian nurses is slowly filling out the hard way that qualifies it as "professional assistance". In view of this, therefore, the folder nursing must and will necessarily become an increasingly indispensable tool and indispensable for the nursing staff in order to ensure proper nursing care.
Italian legislation was already adequate indication of the WHO since 1973 with the law n.795, which states that "professional nurse is essential to observe the conditions or states that cause significant physical or emotional ripercursioni on health and to communicate such observations to other members of the group health. "Too bad the law, though significant, does not indicate which mode you were to make such disclosure. Only 17 years after the Italian State issues the DPR 384, 1990, with which it is stated that "should enable a model of care infermieristica che, nel quadro di valorizzazione della specifica professionalità consenta, anche attraverso l’adozione di una cartella infermieristica, un progressivo miglioramento delle prestazioni infermieristiche erogate al paziente.”
Infine, il D.M.739/94 (il profilo professionale dell’infermiere) e, da ultimo, la legge n. 42/99 (la legge che abroga il mansionario) hanno completato il quadro, trasformando l’infermiere da un semplice esecutore a un professionista della salute, fondata da conoscenze scientifiche, da propri modelli teorici scientificamente approvati, dal codice deontologico e della responsabilità propria dell’infermiere.
Visto che la legislazione italiana si è uniformata indication to the WHO, is now nurse to promote and promulgate its own autonomy in Nursing and go from one model to "technical" merely executive, based on routine activities, which inevitably leads to standard care, for model a "professional" active and proactive, providing personalized assistance to each individual patient. The professional autonomy, requires a good cultural preparation, a solid technical ability, awareness of the importance of the human and ethical issues that has always characterized the actions of those who are in continual contact with the patient, skills those that can not be improvised but require careful and constant evaluation of the patient through the nursing care plan for this purpose it is necessary the introduction of the folder in our nursing departments.
Benefits of nursing
folder The folder is nursing an information tool that gathers information about a range of nursing care allocated to a single elderly person in relation to their pathology. The benefits of nursing
folder are:
ü Encourage continuity of care;
ü Provide assistance custom, thus improving its quality;
ü Documenting the assistance given to the patient;
ü Reduce the time of delivery, because the documentation is updated continuously;
ü Facilitate the identification of pertinent information from the patient;
ü Avoid unnecessary repeats;
ü Avoid forgotten, as every indication is immediately transcribed;
ü Impose a daily assessment of all the needs of nursing both real and potential;
ü The documentation can be used by multiple people;
u can serve as a bank research data infermieristica;
ü Può rappresentare uno strumento informativo di tipo orizzontale a sostegno dell’integrazione fra professionisti;
ü Risulta a supporto dell’evidenza nelle controversie legali;
ü Facilitare l’aggregazione di tutti i dati del paziente evitando inutile perdita di tempo nella ricerca del documento.
Il primo passo per poter elaborare la cartella infermieristica è stato quello di individuare una teoria dell’assistenza infermieristica e adattarla alla realtà della nostra clinica, per poter offrire la migliore assistenza possibile ai nostri pazienti, tenendo conto delle esigenze mediche, diagnostiche, cliniche e personali dei pazienti stessi.
Theoretical model adopted:
The theoretical model adopted is to Marisa Cantarelli, deputy director of the degree course in nursing at the University of Milan, offers his theories into a model for vocational nurses. Calling it a "model of nursing care." The model of
Cantarelli has already been tried and successfully adopted in some national contexts, increasing the degree of satisfaction of nurses and especially patients, by improving the quality of nursing care while maintaining the same resources.
This is a model that requires nurses, higher scientific knowledge that gives greater autonomy but also requires more motivation.
Represents, meanwhile, a strong satisfaction for the nurse, the transition from technical assistance to support standardized performance, customized to the individual patient (by canceling the boring routine) this step will inevitably increase the motivation of the nurse giving him any Day of the new stimuli. The model of
Cantarelli also considerable merit of being logical, consistent, rational, far from abstruse metaphysical and difficult philosophical theories, applicable to the concrete reality with relative ease. It also allows you to record and measure the nursing with great precision and sophistication.
model adopted folder nursing: nursing
The folder we created uses:
ü A cover four pages;
ü nursing care plan with nursing diagnoses and potential;
ü Assessment of daily needs' nursing;
ü sheet parameters;
ü Diary nursing;
ü Documents to monitor PA, CT, hourly diuresis, water balance;
ü Sheet therapy;
ü Reminder radiological and blood examinations performed;
ü Check list pre- surgery.
The title:
The first title page collects demographic information with their telephone numbers is a relative of both the referring physician, thereby avoiding unnecessary loose sheets, with 80% of cases are lost. In addition, we collect clinical information with vital signs.
the second page, however, we will evaluate all the needs of nursing, as well as the transcription of all the blood tests, radiological and requests for blood or blood products.
The first two pages of the title must be completed at admission, this method leads to some advantages:
allow the nurse to know the patient and to empathize with the object;
provide the patient with the more precise information on its therapeutic procedure, so the patient will feel safe and welcomed in the department, earning, so the patient's trust;
allow the patient to ask questions on any concerns;
avoid forgetfulness because all prescriptions are transcribed immediately, snubbing the sheet of paper.
In the third and fourth page of the title, are documented and monitored of any principals, the patient may present during his clinical course, further, that a medical specialist visits and collaboration with other professionals related to nurses.
The care plan:
The nursing care plan is a tool that allows the nurse to provide personalized assistance and not standardized. As we all know everyone has different times, therefore, can not be expected that all patients who have suffered the same type of medical procedure / surgery will achieve the autonomy of the need for nursing care at the same time as There are variables to consider, such as: age-related diseases, the pain threshold, the lifestyle, the motivation of the patient;
etc ... ... So it is up to the nurse, customize 'assistance nursing through a nursing diagnosis needs compromise, which follows the formulation of which is to be achieved, taking into account the time of healing that requires medical / surgical and all those variables that may interfere with the achievement of ' objective. Once the diagnosis and identify the target with its time, it remains to plan the nursing interventions needed to achieve the same goal in the allotted time, then, it will make an assessment about whether or not the objective fixed, in the event of failure or partial achievement of the objective, we starts with the process of formulating a new nursing diagnosis nursing.
The daily assessment of the need for nursing care:
This document is a framework for easy reference and a comprehensive view of the patient and his needs for nursing care.
addition, forces and / or allows the nurse to assess all the needs of daily nursing care and report any changes, giving, thus, precise indication of the next turn to colleagues and doctors, avoiding loss of time in finding information, fact , the extra time you can devote to the patient, improving the quality and credibility dell’assistenza infermieristica erogata.
Il foglio dei parametri:
Questo documento ha l’intento di abolire il “quaderno dei parametri”, in quanto su un unico foglio sono trascritti tutti i parametri vitali di tutti i pazienti e siccome il nostro intendo è quello di personalizzare l’assistenza e avere l’andamento globale dell’iter terapeutico, dall’ingresso alle dimissioni, del singolo paziente, abbiamo introdotto nella cartella infermieristica un unico foglio dei parametri, nominale, dove verranno trascritti tutti i parametri vitali.
Inoltre, con questo metodo, si potranno fornire notizie utili ai medici, anche nell’evenienza (molto frequente) di più curanti visiting.
Finally, this method avoids the nurses on duty, to contend for the so-called notebook or parameters to be shuttled from room to room for news on vital signs, violating, so even the privacy of the patient.
nursing Diary: The Diary
nursing replace the "old" issue in this document should be recorded all the new medical indications and all of that information, and have no place in the previous documentation and the nurse are essential to ensure continuity of care.
documents to monitor PA, CT, hourly diuresis, water balance:
These patterns used on medical advice, if any were needed. The sheet
therapy: In the spreadsheet therapy
get written prescriptions for medication. Uniforms
to route of administration, type of drug, amount to be administered, time of administration, suspension therapy.
The reminder of radiological examinations and blood played:
documents that allow easy reference of all the blood tests and X-ray performed during the period of hospitalization.
The pre-operative check list:
The checklist is a checklist of pre-printed, used to verify that all points have been made and that nothing has been forgotten. The check
list pre-operative aims to achieve two objectives:
Ensure the patient is entering the operating room under controlled conditions to avoid problems;
Check for site preparation of the patient and all relevant documentation is present.
Folder nursing written by: Mario Contini and Antonio Lopez.
With the collaboration of: Sabina Caldelari; Daniela Anzelmo;
Barbara Gagliardi, Claudia Pizzuti.
